Shingles Vaccine and Medicare

by admin on July 11, 2018

You may have noticed pharmacies advertising that the shingles vaccine is in stock and available. The CDC's list of recommended immunizations is constantly evolving and the most recent addition is the shingles vaccine for all adults age 60 and over. This has many seniors wondering if they should receive the shot and if Medicare covers the cost.

Should you get the shingles vaccine?

Over 95% of the people in the United States are infected by the Varicella zoster virus at some point in their lifetime. The virus causes the common childhood disease of chickenpox and then lies dormant within the nerve cells. In approximately one third of the population the virus will re-activate later in life as shinglees: a contagious, nasty, blistering rash that can cause sever, debilitating pain that may last for weeks, months or even years (called post herpetic neuralgia). It can also attack the eyes and permanently damage vision (though this is less common).

These numbers equate to over 1 million people being affected by this virus. So it's no surprise that the CDC recommends a single dose of the zoster vaccine Zostavax for men and women 60 years of age and older, even if they have had a prior episode of shingles.

Recently, a study published online in the Journal of Internal Medicine has shown the vaccine to be safe, and well tolerated in a controlled study of 193,000 adults age 50 and over. Studies have also shown the vaccine to be effective; with results similar to those found in clinical trials in 2006 it was first approved. The vaccine reduced the risk of developing shingles by more than half, and minimized the effects of the disease in those that developed it.

The over 60 crowd is often the highest risk group for contracting disease due to declination immunization, co-existing health issues, multiple diagnoses, or even increased stress factors. The CDC recommends the immunizations, but you should consult your doctor to determine if the vaccine is right for you.

How much does it cost and will Medicare pay for it?

Currently, the only vaccines covered under Medicare Part B are: Flu, H1N1, Pneumococcal, and Hepatitis B. So if you have strictly traditional Medicare the answer is no.

Technically, Part D plans will cover the vaccine and administration, but it may require some advance planning and organization on behalf of the beneficiary to ensure the claim gets paid.

In fact, Medicare.gov states:

“Except for vaccines covered under part B, Medicare drug plans must cover all commercially available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

According to Merck, the manufacturer of Zostavax:

“Medicare Part D = Prescription Drug Benefit 90% of Medicare Part D insured individuals are in plans that have ZOSTAVAX on formulary. The availability and amount of reimbursements will depend on a patient's insurance benefit design, including applicable co-pays, coinsurance, deductibles and / or limits. ”

The vaccine is usually around $ 200, so the time and homework required to ensure re-imbursement is worth the investment.

Check specifically with your Part D plan carrier as a first step. Some plans may require prior authorization, which means your doctor must first get approval before you can receive it. Your doctor may need to state that the drug is 'medically necessary' because he feels you are at high risk for contracting the disease for any reason. Some plans and / or some states may also authorize your pharmacist to administrator the vaccine in the pharmacy and can bill insurance plans directly if they are in-network.

To date, the shingles vaccine has been underutilized. Past stocking issues by pharmacies and physician's offices, cost, and challenges with ease of reimbursement under Medicare part D plans are all to blame. Medical spending to treat shingles or its complications totaled $ 566 million in 2005 or an average of $ 525 per patient. When these expenses are projected on the sheer number of people who are subject to developing the disease, it seems the recommendation to receive this vaccine is a prudent one.

As more patients request and file claims for vaccine re-imbursement, hopefully the process will become more routine to claim handlers and the confusion or misinformation regarding whether or not the vaccine is paid for and how, will diminish over time.